Journal of Telemedicine and Telecare最新文献

Introduction: Videoconferencing psychotherapy (VCP) delivers treatment to individuals with limited access to face-to-face mental healthcare. VCP's effectiveness has been demonstrated for various disorders and therapeutic interventions. However, there is contradictory evidence regarding the therapeutic alliance in VCP as compared to psychotherapy in person (PIP). This meta-analysis examines whether therapeutic alliance differs by psychotherapy's delivery format, namely VCP versus PIP.

Methods: We searched five databases for trials comparing the therapeutic alliance in VCP and PIP, wherein the therapeutic alliance was rated by either patients or therapists or both. Eighteen publications were included, and the difference between VCP and PIP was assessed. Furthermore, we tested possible moderators of the difference in therapeutic alliance between VCP and PIP by meta-regression, and we assessed the risk of bias of this meta-analysis.

Results: The meta-analysis revealed no statistically significant difference in the therapeutic alliance between VCP and PIP for alliance ratings by patients (SMD = -0.09; 95% CI = -0.26; 0.07) as well as by therapists (SMD = 0.04; 95% CI = -0.17; 0.25). No significant moderators were found.

Discussion: In this meta-analysis, VCP and PIP did not differ with respect to the therapeutic alliance as rated by either patients or therapists. Further research is required into mechanisms driving the therapeutic alliance in VCP and PIP.

Introduction: Using a human factors engineering approach, the Johns Hopkins Personalized Pain Program adopted telemedicine for perioperative pain management in response to the COVID-19 pandemic. This study examines the impact of telemedicine adoption on the quality and outcomes of perioperative pain management.

Methods: A mixed-methods study with a convergent parallel design was conducted. From June 2017 to December 2021, 902 patients participated in the Personalized Pain Program. Quantitative data on daily opioid consumption, pain severity and interference, physical and mental health status, and patient satisfaction and engagement were continuously collected with all patients using chart review and patient surveys. Beginning 23 March 2020, the Personalized Pain Program transitioned to telemedicine. A pre-post quasi-experimental design was used to examine the impact of telemedicine. In addition, qualitative interviews were conducted with 3 clinicians and 17 patients to explore their experience with telemedicine visits.

Results: The monthly number of new patients seen in the Personalized Pain Program did not significantly change before and after telemedicine adoption. Compared to patients having in-person visits before the pandemic, patients having telemedicine visits during the pandemic achieved comparable improvements in daily opioid consumption, pain severity and interference, and physical health status. While telemedicine helped overcome many challenges faced by the patients, the limitations of telemedicine were also discussed.

Conclusion: The COVID-19 pandemic stimulated the use of telemedicine. To facilitate telemedicine adoption beyond the pandemic, future research is needed to examine best practices for telemedicine adoption and provide additional evidence on the effectiveness of telemedicine.

Introduction: Teleneurocritical care (TNCC) provides virtual care for hospitals who do not have continuous neurointensivist coverage. It is not known if TNCC is cost effective nor which variables impact the total billed charges per patient encounter. We characterize cost, defined by charge characteristics of TNCC compared to in-person neurocritical care (NCC), for patients with acute ischemic or hemorrhagic stroke requiring ICU care.

Methods: We performed a retrospective review from 2018 to 2021 of prospectively collected multinstitutional databases from a large, integrated, not-for-profit health system with an in-person NCC and spoke TNCC sites. The primary outcome was the total billable charge per TNCC patient with acute ischemic or hemorrhagic stroke compared to in-person NCC. Secondary outcomes were functional outcome, transfer rate, and length of stay (LOS).

Results: A total of 1779 patients met inclusion criteria, 1062 at the hub in-person NCC hospital and 717 at spoke TNCC hospitals. Total billed patient charges of TNCC were similar to in-person NCC (median 104% of the cost per in-person NCC patient, 95% CI: 99%-108%). From 2018 to 2021, the charge difference between TNCC and NCC was not different (r²  =  0.71, p  =  0.16). Both age and length stay were independently predictive of charges: for every year older the charge increased by US $6.3, and every day greater LOS the charge increased by $2084.3 (p < 0.001, both). TNCC transfer rates were low, and TNCC had shorter LOS and greater favorable functional outcome.

Discussion: TNCC was associated with similar patient financial charges as compared to in-person NCC. Standardization of care and the integrated hub-spoke value-focused operational procedures of TNCC may be applicable to other healthcare systems, however, further prospective study is needed.

Introduction: Many patients used telehealth services during the COVID-19 pandemic. In this study, we evaluate how different factors have affected telehealth utilization in recent years. Decision makers at the federal and state levels can use the results of this study to inform their healthcare-related policy decisions.

Methods: We implemented data analytics techniques to determine the factors that explain the use of telehealth by developing a case study using data from Arkansas. Specifically, we built a random forest regression model which helps us identify the important factors in telehealth utilization. We evaluated how each factor impacts the number of telehealth patients in Arkansas counties.

Results: Of the 11 factors evaluated, five are demographic, and six are socioeconomic factors. Socioeconomic factors are relatively easier to influence in the short term. Based on our results, broadband subscription is the most important socioeconomic factor and population density is the most important demographic factor. These two factors were followed by education level, computer use, and disability in terms of their importance as it relates to telehealth use.

Discussion: Based on studies in the literature, telehealth has the potential to improve healthcare services by improving doctor utilization, reducing direct and indirect waiting times, and reducing costs. Thus, federal and state decision makers can influence the utilization of telehealth in specific locations by focusing on important factors. For example, investments can be made to increase broadband subscriptions, education levels, and computer use in targeted locations.

Introduction: The rapid evolution and implementation of virtual care technologies for clinical use often exceeds the development of standardized implementation protocols, leading to gaps in the equitable and sustainable adoption of virtual care services, particularly in rural and remote areas. This paper introduces a comprehensive evaluation tool designed to assess community capacity and readiness for virtual care.

Methods: The development of the tool was informed by experiences from the Virtual Care and Robotics Program at the University of Saskatchewan. It involved a collaborative, multi-stakeholder approach that engaged healthcare leaders, IT experts and community healthcare workers. This iterative process included defining evaluation categories, mapping evaluative domains and refining the tool into a user-friendly checklist manual.

Results: The tool identifies three key domains for assessing readiness: clinical needs, technology infrastructure and human resources/workflows. It was piloted in the remote community of Fond du Lac, Saskatchewan, where it successfully qualified the community for implementing telerobotic ultrasound services. The tool facilitated local engagement and highlighted the community's specific needs and readiness, enhancing the implementation process.

Conclusion: This evaluation tool contributes to bridging the gap between the rapid deployment of virtual care technologies and the need for comprehensive, standardized implementation protocols. It offers a structured, practical approach to assessing and enhancing community readiness for virtual care while promoting successful clinical implementation and equitable access to healthcare.

Background: Inadequate counseling at patient discharge from the emergency department can lead to adverse patient outcomes. Virtual discharge counseling can address gaps in discharge counseling and improve patients' understanding of instructions.

Methods: A previously established virtual discharge counseling program was scaled across three emergency departments and expanded to 13 diagnoses. Utilizing a standardized protocol and script, counselors performed virtual discharge counseling via a remote, secure teleconference platform in the patients' preferred language.

Results: Virtual discharge counseling was performed with 166 patients. COVID-19, back pain, and headache were the most frequent diagnoses. The median counseling time was 14 min. Median counseling time for English was 11 min, versus 20 min for other languages (p < 0.001). Counseling times were the longest for COVID-19 and diabetes (18 min for each).

Conclusion: We demonstrate the scalability of a virtual discharge counseling program. Our findings can assist in targeting virtual discharge counseling resources for limited English-proficiency patients and specific diagnoses that require longer counseling times.

Introduction: Several barriers can preclude people with type 2 diabetes (T2D) from in-person exercise session participation. Telehealth may be an alternative mode of service delivery to increase uptake. We evaluated the feasibility, safety and preliminary efficacy of delivering group exercise via telehealth for people with T2D.

Methods: Sixteen people with T2D (age 59.9 ± 12.7 years, 63% male, duration of T2D 11.5 ± 11.1 years) underwent an 8-week telehealth-delivered group exercise intervention. Weekly supervised sessions incorporated whole-body aerobic and resistance exercises, followed by education. Feasibility was evaluated by recruitment, enrolment, attendance and attrition rates, the practicality of telehealth delivery, and participant feedback. Adverse events were monitored throughout (safety). Preliminary efficacy was determined from changes in glycaemic control, body composition, blood pressure, exercise capacity, neuromuscular strength/fitness, quality of life and physical activity levels. The agreement/reliability of in-person clinician-measured versus telehealth-supervised participant-self-measured assessments was also evaluated.

Results: Feasibility was supported by high attendance (97.1%) and low attrition (81%). All (100%) participants reported they would participate in telehealth-delivered exercise interventions in the future and would recommend them to other people with T2D. No serious adverse events were reported. There were improvements in hip circumference (Cohen's d -0.50), diastolic blood pressure (-0.75), exercise capacity (1.72), upper body strength (1.14), grip strength (0.58), health-related quality of life (0.76-0.81) and self-reported physical activity (1.14). Participant-self-measured assessment of body weight, 2-min step test and 30-sec sit-to-stand test were deemed acceptable.

Discussion: Telehealth-delivered group exercise appears feasible, safe and efficacious for people with T2D. These findings warrant further exploration in a powered trial.

Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12622000379718).

Introduction: Electronic consultations (eConsults) have been implemented by numerous academic medical centers (AMCs) to improve communication and address access to specialty care. As these models proliferate, we must understand their comparative benefit and use in various settings.

Methods: This retrospective, descriptive analysis compares eConsult utilization trends at an AMC that has deployed an internal effort and an external pivot. Relevant metrics are presented using counts and proportions or median and range where appropriate.

Results: The internal AMC program demonstrated sustained growth from years 1 through 6, while the external pivot demonstrated considerable growth in year 1, followed by a steady decline in subsequent years. Endocrinology generated the highest number of eConsult orders in both programs (AMC 21%, external pivot 16%). Conversion rates to in-person visits were higher in the external pivot (22%) than in the internal AMC program (14%). Median response time across all specialties was faster (17 hours) for the AMC program than the external pivot (23 hours). The median number of eConsults ordered by any single primary care provider was 3 in both programs. The percentage of providers using the eConsult ordering system only once was approximately 30% in both programs. eConsults were primarily ordered by physicians (68%) at the AMC and physician assistants (40%) in the external pivot.

Discussion: The current study highlights similarities and differences between internal and external eConsult programs that can inform future "right-sizing" of care according to patient needs while promoting local care delivery and improving efficiencies at the AMC.

Objectives: To explore patients' preferences regarding virtual consultations (via telephone or video) and to explore healthcare professionals' assessment of whether virtual consultations can maintain the same clinical quality as in-person consultations for outpatient care.

Methods: A cross-sectional survey was conducted among patients with an in-person consultation at the outpatient clinic for internal medicine and among healthcare professionals who treated the patients. The prevalence of preference was determined using descriptive statistics based on cross-tabulated frequencies. Percentages are presented with 95% confidence intervals (95%CI).

Results: In total, 218 patients (response rate 67%) completed the questionnaire; 79 patients (36%) preferred a virtual consultation (95%CI: 30%-43%); telephones were the most popular and preferred by 72 patients (33%; 95%CI: 27%-39%) followed by video preferred by 54 patients (25%; 95%CI: 19%-31%). Regarding contextual factors, male gender and previous experiences with telephone or video consultations were statistically significant predictors in favour of virtual consultations. Healthcare professionals estimated that 58 consultations (21%; 95%CI: 17%-26%) could have been conducted virtually with the same professional and clinical quality as the current in-person consultations.

Conclusions: Current practice does not fully align with patient preferences for virtual visits in internal medicine outpatient clinics. Patients should be given the choice of virtual consultations whenever they are deemed professionally and clinically possible to enhance patient autonomy and satisfaction, while being mindful of speciality-specific considerations.

Introduction: Virtual care and remote monitoring were widely used during the COVID-19 pandemic. However, early evaluations of effectiveness were often inconclusive due to low rates of enrolment and limited data. The aim of this study was to evaluate the effectiveness of virtual care in managing individuals in community-based self-isolation and quarantine in Australia during this pandemic.

Methods: A retrospective cross-sectional study was conducted of individuals admitted to a virtual hospital in Sydney who either tested positive for COVID-19 and required self-isolation, or tested negative but still needed to self-isolate, amidst the Delta wave of the COVID-19 pandemic. Outcome measures included health service utilisation, in-hospital mortality, patient-reported experience measures (PREM), and cost savings resulting from avoided emergency department (ED) presentations.

Results: Out of 9571 individuals admitted, 8544 (89.3%) had COVID-19. Clinical deterioration or acute illness occurred in 2477 (25.9%) individuals, of whom 890 (9.3%) were referred to ED for further assessment or investigation, and 614 (6.4%) were admitted for inpatient treatment. Overall mortality was 0.2%. Out of 1020 individuals who completed the PREM survey, 846 (82.9%) rated the overall virtual care experience as 'good' or 'very good'. Avoided ED presentations possibly resulted in cost savings estimated between AU$691,214 and AU$2,994,540.

Conclusion: Virtual care was successfully used to manage a large number of individuals in community-based self-isolation and quarantine during the COVID-19 pandemic. Scalable pathways for triage, monitoring and clinical escalation via telehealth ensured patient safety and acceptability, and alleviated strain on the broader health system.